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Observational Study
. 2018 Jun 1;3(6):489-497.
doi: 10.1001/jamacardio.2018.0579.

Association of Hospital Performance Based on 30-Day Risk-Standardized Mortality Rate With Long-term Survival After Heart Failure Hospitalization: An Analysis of the Get With The Guidelines-Heart Failure Registry

Ambarish Pandey  1 , Kershaw V Patel  1 , Li Liang  2 , Adam D DeVore  2 , Roland Matsouaka  2 , Deepak L Bhatt  3 , Clyde W Yancy  4   5 , Adrian F Hernandez  2   6 , Paul A Heidenreich  7 , James A de Lemos  1 , Gregg C Fonarow  8   9
Affiliations
Observational Study

Association of Hospital Performance Based on 30-Day Risk-Standardized Mortality Rate With Long-term Survival After Heart Failure Hospitalization: An Analysis of the Get With The Guidelines-Heart Failure Registry

Ambarish Pandey et al. JAMA Cardiol. .

Abstract

Importance: Among patients hospitalized with heart failure (HF), the long-term clinical implications of hospitalization at hospitals based on 30-day risk-standardized mortality rates (RSMRs) is not known.

Objective: To evaluate the association of hospital-specific 30-day RSMR with long-term survival among patients hospitalized with HF in the American Heart Association Get With The Guidelines-HF registry.

Design, setting, and participants: The longitudinal observational study included 106 304 patients with HF who were admitted to 317 centers participating in the Get With The Guidelines-HF registry from January 1, 2005, to December 31, 2013, and had Medicare-linked follow-up data. Hospital-specific 30-day RSMR was calculated using a hierarchical logistic regression model. In the model, 30-day mortality rate was a binary outcome, patient baseline characteristics were included as covariates, and the hospitals were treated as random effects. The association of 30-day RSMR-based hospital groups (low to high 30-day RSMR: quartile 1 [Q1] to Q4) with long-term (1-year, 3-year, and 5-year) mortality was assessed using adjusted Cox models. Data analysis took place from June 29, 2017, to February 19, 2018.

Exposures: Thirty-day RSMR for participating hospitals.

Main outcomes and measures: One-year, 3-year, and 5-year mortality rates.

Results: Of the 106 304 patients included in the analysis, 57 552 (54.1%) were women and 84 595 (79.6%) were white, and the median (interquartile range) age was 81 (74-87) years. The 30-day RSMR ranged from 8.6% (Q1) to 10.7% (Q4). Hospitals in the low 30-day RSMR group had greater availability of advanced HF therapies, cardiac surgery, and percutaneous coronary interventions. In the primary landmarked analyses among 30-day survivors, there was a graded inverse association between 30-day RSMR and long-term mortality (Q1 vs Q4: 5-year mortality, 73.7% vs 76.8%). In adjusted analysis, patients admitted to hospitals in the high 30-day RSMR group had 14% (95% CI, 10-18) higher relative hazards of 5-year mortality compared with those admitted to hospitals in the low 30-day RSMR group. Similar findings were observed in analyses of survival from admission, with 22% (95% CI, 18-26) higher relative hazards of 5-year mortality for patients admitted to Q4 vs Q1 hospitals.

Conclusions and relevance: Lower hospital-level 30-day RSMR is associated with greater 1-year, 3-year, and 5-year survival for patients with HF. These differences in 30-day survival continued to accrue beyond 30 days and persisted long term, suggesting that 30-day RSMR may be a useful HF performance metric to incentivize quality care and improve long-term outcomes.

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Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr DeVore has received research support from Amgen, the American Heart Association, the National Heart, Lung, and Blood Institute, and Novartis and has consulted with Novartis. Dr Bhatt has served on the advisory boards of Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; has served on the board of directors of Boston VA Research Institute and Society of Cardiovascular Patient Care; has served as the chair of the American Heart Association Quality Oversight Committee; has served on data monitoring committees of Cleveland Clinic, Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine, and Population Health Research Institute; has received honoraria from American College of Cardiology for serving as a senior associate editor of clinical trials and news, Belvoir Publications for serving as editor in chief of Harvard Heart Letter, Duke Clinical Research Institute for serving on clinical trial steering committees, Harvard Clinical Research Institute for serving on a clinical trial steering committee, HMP Communications for serving as editor in chief of the Journal of Invasive Cardiology, Journal of the American College of Cardiology for serving as guest editor and associate editor, Population Health Research Institute for serving on a clinical trial steering committee, Slack Publications for serving as chief medical editor of Cardiology Today’s Intervention, Society of Cardiovascular Patient Care for serving as secretary/treasurer, WebMD for serving on Continuing Medical Education steering committees, Clinical Cardiology for serving as deputy editor, National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry Steering Committee for serving as chair, and VA Clinical Assessment Reporting and Tracking Program Research and Publications Committee for serving as chair; has received research funding from Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Ironwood, Ischemix, Lilly, Medtronic, Pfizer, Roche, Sanofi Aventis, and The Medicines Company; has received royalties from Elsevier for serving as editor of Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease; has served as site coinvestigator for Biotronik, Boston Scientific, and St Jude Medical (now Abbott); is a trustee for American College of Cardiology; and has performed unfunded research with FlowCo, Merck, PLx Pharma, and Takeda. Dr Hernandez has received research funding from Janssen, Novartis, Portola, and Bristol-Myers Squibb and has consulted for Bristol-Myers Squibb, Gilead, Boston Scientific, Janssen, and Novartis. Dr Fonarow has received research funding from National Institutes of Health and has consulted for Amgen, Bayer, Janssen, Novartis, Medtronic, and St Jude Medical. No other disclosures were reported.

Figures

Figure.
Figure.. Long-term Mortality Risk and Median Survival Across Hospitals Stratified By 30-Day Risk-Standardized Mortality Rates (RSMRs)
A, Cumulative incidence of mortality in the overall population by quartile. Quartiles ranged from low (Q1) to high (Q4) 30-day RSMR. B, Median survival according to 30-day RSMR among 30-day survivors. Error bars indicate 95% CIs.
See this image and copyright information in PMC

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